Consent to Telehealth Services

I have reviewed this Consent to Telehealth Services with respect to the provision of healthcare services from Wisp’s contracted healthcare entities, including but not limited to Hemlock Medical, Inc., a California Professional Corporation, Hemlock Medical of Kansas, P.A., a Professional Association based in Kansas, and Hemlock Medical of New Jersey, PA, a Professional Association based in New Jersey, and Hemlock Medical of Texas, PA, a Professional Association based in Texas (collectively “Medical Groups”) and their affiliated medical providers (“Providers” or “Provider”) (Medical Groups and Provider/s collectively, Wisp Affiliated Providers). I understand that this consent is supplemental to the Terms of Service.

By checking the box in the Wisp registration flow associated with this Consent to Telehealth, I consent to the following:

• I consent to receiving medical services via telehealth. I understand that, where appropriate, care via telehealth includes a medical examination, consultation via electronic means, and the potential diagnosis and treatment of a medical condition.
• Wisp may disclose information we receive during a telehealth consultation with vendors that provide artificial intelligence services that provide backend support for our Services. I understand that by participating in the session, I will be recorded by Wisp and their service provider.
• I understand that this Consent to Telehealth Services also serves as a formal request by my Provider to determine whether I consent to having my telehealth medical records shared with my primary care provider (or other provider designated by me).
• I understand that if I consent to transferring my medical records to another provider, I should contact my telehealth Provider to arrange such transfer.
• I recognize that my Provider may deem telehealth inappropriate for my specific case. I further understand that there is no guarantee that I will be prescribed any specific medication, and that any prescription or course of treatment is up to the medical and professional judgment of my Provider.
• I understand that I can withdraw my consent for telehealth at any time without affecting my rights to future care, provided that I follow all applicable terms of service.
• I understand that Wisp Affiliated Providers use various security protocols, including, but not limited, to (a) maintaining network physical safeguards applicable for each system used to access, transmit, receive and store PII, PHI and or sensitive company data to ensure that appropriate security is maintained and that access is restricted to authorized employees; (b) physical access rules to limit physical access to PHI, PII and or sensitive company data and the physical location(s) in which such systems are housed; and (c) procedures stating how all media containing PHI, PII and or sensitive company data, will be disposed of in a manner that destroys the data and does not allow unauthorized access to the data.
• I understand that a Provider will be assigned to me. I can request a different, appropriately-licensed Provider, and that I have the right to review the credentials of my assigned Provider or a Provider of my choice.
• I understand that I can request a copy of my medical records be sent directly to my primary care provider or be released directly to me by contacting my Provider to arrange for such transmission.
• I understand that treatment via telehealth is a choice. Treatment via telehealth has benefits, including: ease of scheduling, the ability to access my health records via an online portal, the ability to, a more seamless experience. Treatment via telehealth also has limitations and risks, including the (i) inability to have face-to-face, in person contact between a provider and a patient; (ii) the potential for data breach; and (iii) the lack of a comprehensive, previously existing medical file from my in-person provider, which may have provided additional insights to treatment options.
• I understand that in-person care is an alternative to telehealth and that not all conditions are suitable for telehealth. I also understand that telehealth is not the right modality of treatment for all patients, some of whom prefer in-person providers.
• If I am experiencing a medical emergency, I understand that I should contact 9-1-1 or go to the nearest emergency room. I will not use Wisp’s platform for emergency medical services.
• I understand that I should disclose to my Provider if I have received emergency medical services.

What is Telehealth?

Telehealth is the provision of medical and healthcare services in which the patient and medical provider are not in the same location. To effectuate the provision of medical services in such circumstances, healthcare providers utilize technology, such as diagnostic tools, audio communication, visual communication, and or store-and-forward technology. In some cases, telehealth services are performed synchronously (i.e., with the patient and provider interacting in real time) and in other cases telehealth services are performed asynchronously (i.e., with the patient and provider interacting at different times). Telehealth includes the creation and or transmission of an electronic patient medical record. Not all conditions are suitable for treatment via telehealth.

Additional Notices to Patients of the Following States:

Alaska: If I consent to transferring my medical records to another provider, I understand that I shall contact my Provider directly to arrange for the transmission of these records. (Alaska Stat. § 08.64.364(a)(2)).

Arizona: I consent to treatment via telehealth and I evidence my consent via this electronic format. (Ariz. Rev. Stat. Ann. § 12-2291)

California: I consent to the treatment of telehealth and I evidence my consent via this electronic format. Medical doctors are licensed and regulated by the Medical Board of California. To check up on a license or to file a complaint go to www.mbc.ca.gov,email: licensecheck@mbc.ca.gov, or call (800) 633-2322. For more information visit the California Medical Board’s Notice to Consumers website.

Connecticut: If I consent to transferring my medical records to another provider, I understand that I shall contact my Provider directly to arrange for the transmission of these records. (Conn. Gen. Stat. Ann. § 19a-906).

D.C.: I have been informed of alternate forms of communication between me and a physician for urgent matters. (D.C. Mun. Regs. tit. 17, § 4618.10).

Georgia: I understand that I am entitled to receive clear, appropriate, accurate instructions on follow-up in the event of needed emergent care related to treatment via electronic or other means. (Ga. Comp. R. & Regs. 360-3-.07(7)).

Idaho: I understand that in order to make a formal complaint about a provider, I should visit the medical board’s website, here: https://bom.idaho.gov/BOMPortal/AgencyAdditional.aspx?Agency=425&AgencyLinkID=650

Indiana: I understand that in order to make a formal complaint about a provider, I should visit the medical board’s website, here: https://www.in.gov/attorneygeneral/2434.htm

Iowa: I understand that in order to make a formal complaint about a provider, I should visit the medical board’s website, here: https://medicalboard.iowa.gov/consumers/filing-complaint

Kansas: If I consent to transferring my medical records to another provider, I understand that I shall contact my Provider directly to arrange for the transmission of these records, and my Provider shall send within three business days a report to my primary care or other treating physician of the treatment and services rendered to me in my telehealth encounter . (Kan. Stat. Ann. § 40-2,212(2)(d)(1)(A)).

Kentucky: I understand that in order to make a formal complaint about a provider, I should visit the medical board’s website, here: https://kbml.ky.gov/grievances/Pages/default.aspx

Louisiana: I understand that the relationship between provider and patient is one that is governed by various laws and codes of ethics. I understand and consent to the fact that other health care providers may be involved in the management of my treatment. I further understand that I may decline to received medical services via telemedicine and may withdraw from such care at any time. (46 La. Admin. Code Pt XLV, § 7511).

Maine: I understand that in order to make a formal complaint about a provider, I should visit the medical board’s website, here: https://www.maine.gov/md/discipline/file-complaint.html

Nebraska: I understand that I retain the option to refuse the telehealth consultation at any time without affecting my right to future care or treatment and without risking the loss or withdrawal of any program benefits to which I would otherwise be entitled. I understand that all existing confidentiality protections shall apply to my telehealth consultation. I understand that I shall have access to all medical information resulting from the telehealth consultation as provided by law for access to my medical records. Neb. Rev. Stat. § 71-8505

New Hampshire: If I consent to transferring my medical records to another provider, I understand that I shall contact my Provider directly to arrange for the transmission of these records. I understand that I may discuss with my Provider whether this is appropriate for my situation. (N.H. Rev. Stat. § 329:1-d).

New Jersey: I understand that I have the right to request a copy of my medical information and, if deemed appropriate by my Provider, I affirmatively consent to having my medical information forwarded directly to my primary care provider or health care provider of record, or upon my request, to other health care providers. I understand that if I don’t have a primary care provider or other health care provider of record, my Provider may advise me to contact a primary care provider, and, upon request by me, my Provider may assist me with locating a primary care provider or other in-person medical assistance that, to the extent possible, is located within reasonable proximity to me. I understand that I shall contact my Provider directly to arrange for the transmission of these records. (N.J. Rev. Stat. Ann. § 45:1-62).

Oklahoma: I understand that in order to make a formal complaint about a provider, I should visit the medical board’s website, here: http://www.okmedicalboard.org/complaint. With respect to the Board of Osteopathic Examiners I understand that they may be reached here: https://www.ok.gov/osboe/faqs.html

Rhode Island: I understand that if my Provider and I use e-mail or text-based technology to communicate, then I understand the types of transmissions that will be permitted (including but not limited to prescription refills, appointment scheduling and patient education). I further understand the circumstances when alternate forms of communication or office visits should be utilized, such as when I or my Provider do not deem telehealth an appropriate medium for my consultation, diagnosis or treatment. I have also reviewed Wisp’s and Medical Group’s data security measures, such as encryption of data and utilization of other reliable authentication techniques, as well as potential risks to privacy. I agree to hold harmless my Provider, the Medical Groups, Wisp Affiliated Providers, and Wisp for information lost due to technical failures; and I provide my express consent to forward my patient-identifiable information to a third party. I acknowledge that my failure to comply with this agreement may result in the Medical Group provider terminating the email relationship. (Rhode Island Medical Board Guidelines).

South Carolina: If I consent to transferring my medical records to another provider, I understand that I shall contact my Provider directly to arrange for the transmission of these records. I understand that my medical records may only be distributed in accordance with applicable law. (S.C. Code Ann. § 40-47-37).

South Dakota: I understand that disclosures regarding the delivery models and treatment methods or limitations. S.D. Codified Laws § 34-52-3.

Texas: If I consent to transferring my medical records to another provider, I understand that I shall contact my Provider directly to arrange for the transmission of these records. (Tex. Occ. Code Ann. § 111.005). Furthermore, I have received and reviewed the following notice: NOTICE CONCERNING COMPLAINTS -Complaints about physicians, as well as other licensees and registrants of the Texas Medical Board, including physician assistants, acupuncturists, and surgical assistants may be reported for investigation at the following address: Texas Medical Board, Attention: Investigations, 333 Guadalupe, Tower 3, Suite 610, P.O. Box 2018, MC-263, Austin, Texas 78768-2018, Assistance in filing a complaint is available by calling the following telephone number: 1-800-201-9353, For more information, please visit our website at www.tmb.state.tx.us.

Utah: By this notice, I have been informed (i) additional fees charged for telehealth services, if any, and how payment is to be made for those additional fees, if the fees are charged separately; (ii) to whom my health information may be disclosed and for what purpose; (iii) my rights with respect to patient health information; (iv) appropriate uses and limitations of the site, including emergency health situations, as provided in among other places this Consent to Telehealth Services and any applicable terms of use. I understand that the telehealth services Medical Group provides meets industry security and privacy standards, and comply with all laws referenced in Subsection 26-60-102(8)(b)(ii). I have been warned of potential risks to privacy notwithstanding the security measures. I understand that information may be lost due to technical failures, and agree to hold the provider harmless for such loss. I have been provided with the location of Wisp’s website owner-operator, location and contact information. I understand that Wisp and the Medical Group work with third parties to receive patient identifiable information related to the services provided, including but limited to the fulfillment of any prescriptions. Other such disclosures are provided in policies and terms of service associated with this platform. (Utah Admin. Code r. 156-1-602).

Virginia: I have received details on security measures taken with the use of telemedicine services, such as encrypting date of service, password protected screen savers, encrypting data files, or utilizing other reliable authentication techniques, as well as potential risks to privacy notwithstanding such measures; I agree to hold harmless my Provider, the Medical Groups, Wisp Affiliated Providers, and Wisp for information lost due to technical failures; and I provide my express consent to forward my patient-identifiable information to a third party. (Virginia Board of Medicine Guidance Document 85-12).

Vermont: I understand that all services my Provider delivers to me through telemedicine will be delivered over a secure connection that complies with the requirements of HIPAA. I understand that receiving store-and-forward telehealth services via Medical Group does not preclude me from receiving real-time telemedicine or face-to-face services with the distant provider at a future date. (Vt. Stat. Ann. § 9361). If deemed appropriate by my provider, I consent to a telephone consultation (as opposed to a video consultation) to receive care via telemedicine. I understand that in order to make a formal complaint about a provider, I should visit the medical board’s website, here: http://www.healthvermont.gov/health-professionals-systems/board-medical-practice/file-complaint; and here with respect to osteopathic professionals, https://www.sec.state.vt.us/professional-regulation/file-a-complaint-employer-mandatory-reporting.aspx

Last updated June 13th, 2024